Purpose <p>This study aims to identify factors associated with symptom distress and investigate the mediating roles of intestinal symptoms self-management behavior in rectal cancer patients after sphincter-preserving surgery between self-efficacy and symptom distress by structural equation model.</p> Methods <p>This study involved 177 rectal cancer patients after sphincter-preserving surgery from June 2022 to December 2022. Data were collected using a general information questionnaire, the Intestinal Symptoms Self-Management Behavior Questionnaire, the Strategies Used by People to Promote Health Scale, and the Anderson Symptom Inventory for Colorectal Cancer. Data analyses included descriptive statistics, independent <i>t</i>-test, correlation analysis, and multiple linear regression analysis. Additionally, a structural equation model was utilized to explore the mediating role of intestinal symptoms self-management behavior.</p> Results <p>Participants reported a medium level of symptom distress (46.78 ± 27.74). Symptom distress was negatively correlated with self-efficacy and intestinal symptoms self-management behavior. Multiple linear regression analysis revealed that gender, family monthly income, course of disease, self-efficacy, and intestinal symptoms self-management behavior were significant predictors of symptom distress. Mediation analysis indicated that intestinal symptoms self-management behavior partially mediated the relationship between self-efficacy and symptom distress, with a mediation effect size of −0.140 and a total effect proportion of 33.3%.</p> Conclusions <p>Intestinal symptoms self-management behavior plays a partial mediating role between self-efficacy and symptom distress, which should be considered in future intervention research.</p>